| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $2.57 | $2.57 | $79.23 | |
Molina
| Facility | $3,000.00 | $3,000.00 | $3,000.00 |
Pharmacy - Other Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $2.57 | $2.57 | $79.23 | |
Molina
| Facility | $3,000.00 | $3,000.00 | $3,000.00 |